Consultant in Paediatric Allergy & Immunology

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Expertise

I deal with all aspects of paediatric allergy and immuology and am committed to providing the best care to all of my patients.

Allergic diseases have become increasingly common, with 1 in 4 people in the UK suffering from allergy. There is often a clear progression of allergic symptoms with eczema and food allergy often being the first manifestation of allergic disease, followed by asthma and hayfever. This association of symptoms has been referred to as the allergic march.

As most of these allergic diseases are linked and develop in early infancy and childhood, a paediatric allergy specialist is ideally placed to care for these children, providing a holistic as well as longitudinal perspective to each child’s health care needs. Increasingly, the emphasis is shifting to early diagnosis, intervention and treatment.

Dr Helen Cox has considerable expertise in the diagnosis and management of eczema, urticaria, food allergy, anaphylaxis, asthma and hayfever. Her areas of specialist interest include managing the child with multi-system allergic disease who may have two or more of the above allergic conditions. She has considerable expertise in treating children with difficult eczema, helping to tease out the allergic and non-allergic factors that contribute to skin inflammation and is a well respected lecturer on the subject of "allergy and eczema" both within the UK and abroad.

She runs a busy food allergy service managing children who present with either immediate symptoms (nettle rash, facial swelling, anaphylaxis) or with more delayed presentations (ie colic, reflux, diarrhoea, constipation, failure to thrive). She has established links with several paediatric gastroenterologists in London and works closely with a superb team of paediatric dietitians, allergy nurses, speech and language therapists (for aversive feeding and swallowing difficulties) and clinical psychologists.

She is one of the few Paediatric Allergists offering injectable and sublingual immunotherapy to children with severe hayfever or venom allergy. Drug allergy testing is offered.

FACT SHEET

Severity varies considerably from mild intermittent symptoms, which may be trivial, to severe daily symptoms with considerable impact on quality of life, sleep and daytime concentration.

Symptoms are frequently under recognized and under treated

Inadequately treated allergic rhinitis has been shown to influence academic performance with children at GCSE level been shown to drop a grade between their winter and summer exams when poorly controlled.

Allergic rhinitis is frequently associated with asthma and can impact on asthma symptoms.

Medical treatment is highly effective in controlling symptoms

Immunotherapy can significantly alter the disease course with reduction in symptoms and need for medication.

WHAT TO EXPECT

A detailed clinical history will establish the severity and duration of symptoms and impact on quality of life.

Lung function testing using computerized spirometry and exhaled nitric oxide is carried out in children aged 6 years and above.

If required, blood testing will be done on the same day.

An individual treatment plan is provided based on the above clinical assessments, with treatment being tailored to each child’s specific needs

Advice on allergen avoidance is given

The allergy nurse in clinic will demonstrate your child’s asthma inhalers to ensure that these are being given correctly.

When appropriate, Dr Cox may discuss novel treatments for asthma with you.

NOVEL TREATMENTS FOR ASTHMA

Immunotherapy is increasingly being used for the treatment of chronic asthma. Specific immunotherapy to grass and tree pollen is highly effective in treating seasonal asthma ie asthma confined to the pollen season. Sublingual immunotherapy to house dust mite has been shown in several studies to be effective for treating asthma in patients with proven house dust mite allergy.

Xolair (Anti-IgE): This treatment is licensed for severe refractory asthma. Treatment is very expensive and therefore usually requires referral to an NHS tertiary asthma clinic, where treatment is justified based on measurable scores of disease outcome.

2/3 of children with eczema develop either asthma or allergic rhinitis

Early detection of food and inhalant allergens allows for better understanding of the potential trigger factors for eczema and overall improvement in disease management

WHAT TO EXPECT

Children attending the clinic for eczema will have a detailed clinical history focusing on the possible trigger factors for their eczema and current use of creams and medications. Your child’s eczema will be scored in terms of severity and impact on quality of life.

As eczema frequently coexists with other allergic diseases (ie asthma, allergic gut disease), a multi-system approach is adopted to address the needs of the whole child.

Immediate reactions to foods cause a range of symptoms affecting the skin, gut and respiratory system. Allergy tests are usually positive.

“Anaphylaxis” is the term used to describe a severe immediate reaction to food causing breathing difficulty or a drop in blood pressure.

Delayed reactions to foods can cause eczema within 72 hours of food ingestion and/or reactions in the gut, leading to a range of symptoms including vomiting, reflux, abdominal pain, bloating, loose stools, constipation and faltering growth. Allergy tests are often negative and the diagnosis relies on the clinicians interpretation of the clinical history and signs.

Correct identification of dietary allergens allows for avoidance and reduction or indeed resolution of symptoms.

Unsupervised dietary avoidance in children can be dangerous, placing children at risk of vitamin and mineral deficiencies.

WHAT TO EXPECT

A thorough clinical history is essential to ensure the accurate diagnosis of food allergy. The clinical history will detail any possible immediate reactions to foods as well as delayed reactions to foods and the timing of food introductions.

Allergy testing will be carried out (skin prick testing and/or specific IgE testing). A diagnosis will be made based on combining the results of the allergy tests with the information obtained from the clinical history.

A personalized allergy management plan will be given detailing how to treat future food allergic reactions. Training in the use of an adrenaline autoinjector is an important part of the consultation if adrenaline is prescribed.

FACT SHEET

Immunotherapy is the practice of administering gradually increasing doses of an allergen extract (eg pollen) in order to reduce the symptoms of hayfever or asthma that it causes.

Immunotherapy modifies the immune response leading to a 40-60% reduction in symptoms and need for medication.

The effect of treatment is sustained for many years after discontinuation of treatment. In this way it differs greatly from all other standard medications, which do not alter the course of allergic disease.

Immunotherapy is available as injectable treatment (subcutaneous immunotherapy or SCIT) or as oral treatment in the form of drops or tablets (sublingual immunotherapy or SLIT)

SUBCUTANEOUS IMMUNOTHERAPY (SCIT)

Pre-seasonal treatment with injectable immunotherapy is currently offered to grass and tree pollen sufferers with severe seasonal symptoms. Treatment is typically initiated 3 months before the pollen season.

SCIT is very effective in the majority of patients, with a 20% reduction in symptoms in year one and a 40%-60% reduction in symptoms and need for medication by year three. Rarely, the treatment fails to reduce symptoms.

Pollinex Quattro is given as 4 injections administered 3-4 months pre-seasonally, given at 1-2 week intervals. The treatment cycle needs to be repeated each year prior to the pollen season. This treatment has the advantage of not relying on individual patient compliance.
Tree pollen SCIT is usually initiated in Dec – Jan. Grass pollen SCIT is usually initiated in Jan-Feb.

SUBLINGUAL IMMUNOTHERAPY (SLIT)

Sublingual immunotherapy (SLIT) entails the placing of drops or a soluble tablet under the tongue for 2 minutes. Therapy is initiated in clinic but then continued at home. Treatment is taken daily for the duration of the course. The total duration is for 3 years.

SLIT is highly effective treatment provided it is taken regularly, with a 40-60% reduction in symptoms and need for medication. The effect is noticed from year 1 of treatment.

Pre-seasonal treatment is initiated 2-3 months before the pollen season and continued for a further 3 months during the pollen season. This is repeated each year for 3 years.

Products currently available include:Staloral drops for tree pollen - commenced Dec-Jan and given once daily x 6 monthsOralairtablets for grass pollen – commenced Feb-March and continued once daily x 6 months

Perennial treatment is given once daily or 3 x weekly for 3 years. Treatment is highly effective provided it is taken daily. Poor compliance with treatment will influence treatment outcomes.

FACT SHEET

Urticaria (hives) is a common skin manifestation of allergy. This is often associated with angioedema (swelling) of the face, hands, feet or genitalia. The reactions are usually short-lived subsiding within hours or 1-2 days of allergen exposure.

Viruses can cause urticaria and angioedema and this is often mistaken for allergy. Viral triggered urticaria may persist for days, whilst the virus is in the body, but then subsides spontaneously.

Urticaria can be more persistent and become chronic with skin lesions being present daily for 6 weeks or more. Chronic urticaria is rarely caused by an allergy. A circulating autoantibody is frequently present.

Some persistent forms of urticaria are triggered by physical factors such as cold, water, sunshine, pressure or exercise.

WHAT TO EXPECT

A thorough clinical history will help identify the cause of your child’s urticaria in most cases.
Allergy testing may be required to confirm or refute allergy.
In chronic urticaria, blood tests need to be taken to check thyroid function and for the presence of circulating autoantibodies.
In cold urticaria, an ice cube challenge test will be carried out in clinic.